A surge in appendicitis: Management of paediatric appendicitis during the COVID-19 surge in the Royal Belfast Hospital for Sick Children.

BACKGROUND: Traditional surgical dogma is that paediatric appendicitis necessitates an appendicectomy; however there is an increasing cohort of evidence suggesting that non-operative management (NOM) using antibiotic therapy is safe and effective. During the COVID-19 surge (April - June 2020) with centralization of paediatric surgical care and risks from anaesthetics to both patients and staff a NOM pathway was used to manage clinically diagnosed appendicitis in the Royal Belfast Hospital for Sick Children (RBHSC). METHODS: Prospective data collection was undertaken of all children (<16 years) diagnosed with appendicitis who entered the NOM pathway in RBHSC from 01/04/2020 to 30/06/2020. This was compared to a cohort from the same timeframe in 2019. Primary end-points were inpatient success rate of NOM and 30-day success rate of NOM (success defined as no appendectomy performed). RESULTS: 47 patients completed the NOM pathway, with 43% (20/47) suspected to have complicated appendicitis. The cohort was similar to that of 2019 in terms of age (p=0.1) and sex (p=0.8), but was 155% larger (42 v. 20).For those with simple appendicitis, there was a 96% (26/27) success rate of NOM on discharge, with a 93% (25/27) 30-day success rate. For complicated appendicitis, there was a 40% (8/20) success rate on discharge, with a 30% (6/20) 30-day success rate. CONCLUSION: The use of a NOM pathway for paediatric appendicitis during the COVID-19 surge in Northern Ireland was safe and effective for staff and patients. With a small sample size and restricted follow up more evidence is required to prove if this is an effective treatment modality with a return to normal theatre availability. In the interests of antibiotic stewardship we would not advocate NOM pathways utilisation by non-surgical clinicians.

Multiple atresia of the small intestine: a 20-year review.

BACKGROUND: Multiple intestinal atresia (MIA) presents with a wide spectrum of bowel pathologies. Its treatment is a challenging task since restoration of anatomical continuity of the affected intestine must be balanced against preservation of the intestine's maximal length. MATERIAL AND METHODS: A retrospective analysis of the medical notes of 26 patients with MIA treated over a 20-year period between 1986 - 2006 was undertaken with a special emphasis on the clinical and surgical perspectives. RESULTS: All 26 cases of MIA were sporadic with no familial history. The mean gestational age and birth weight were 36.1 weeks and 2781 g, respectively. Twenty-three of the infants underwent operative repair within the first days of life. Three patients with gastroschisis had a delayed diagnosis of bowel atresia. The number of atresias per patient ranged from 2 to 10. In 24 newborns atresias were confined to the small bowel, with 2 other patients having additional obstruction of the ascending colon. Various combinations of anatomical types of atresias were found, with type I and type III occurring in 19 patients each. Type II was diagnosed in 7 newborns. Surgical management of MIA consisted of one-stage restoration of bowel continuity with multiple anastomoses and/or enteroplasties in 22 patients. Four patients had an enterostomy performed at initial operation. Early and late postoperative complications requiring operative treatment occurred in 8 patients. The duration of parenteral nutrition ranged from 6 days to 20 months, exceeding 100 days in 6 children. The follow-up ranges from 3 months to 16 years. All the patients are alive and are on a full oral diet. CONCLUSION: Clinical observations of sporadic cases of MIA confined to the small bowel lend support to the hypothesis of a vascular incident etiology. One-stage restoration of intestinal continuity with preservation of maximal intestinal length should be the basic principle of any operative management of MIA. Despite a relatively high morbidity related to the primary damage of the fetal intestine, excellent results with 100 % survival rates can be obtained. After taking the differences in pathogenesis, anatomical and histological features, and the prognosis for sporadic and hereditary forms of MIA into account, these two entities should be classified separately in a modified classification of intestinal atresia.

The role of the public in water fluoridation: public health champions or anti-fluoridation freedom fighters?

OBJECTIVE: Using the opportunity of pretesting a leaflet for the general public on water fluoridation, their views were also sought on the issue as a whole. DESIGN: Qualitative research using focus group discussions led by an experienced moderator. SETTING: Among the general public living in north east England. SUBJECTS: Members of the public living in both fluoridated and non-fluoridated areas in three age bands (20-35, 36-50 and 50+) and by social class. RESULTS: The study found: the low priority given to dental health; how emotive the subject of water is; the variable knowledge of fluoride in relation to dental and general health; and the desire for information if new water fluoridation schemes are planned. CONCLUSIONS: The research confirmed public support for water fluoridation but highlighted the place of public health professionals in championing water fluoridation because of public apathy.

General anaesthesia: who decides, and why?

This study sought to determine the relative influence dentists and parents have on the decision to give a general anaesthetic to a child, and to identify the factors that influence that decision. The research involved group discussions and in-depth interviewing as a method of investigating attitudes and behaviour in greater detail. The results indicated that parents are not able to make informed choices about general anaesthesia being used on their child; the dentist has the greatest influence on the decision to use general anaesthesia; and that this decision is often influenced by non-clinical factors. These non-clinical factors were identified as: the norms of the dentist, overall attitudes to general anaesthesia and how general anaesthesia provision was structured locally. The findings suggest that any attempt to reduce the current levels of general anaesthesia further must address these factors, whilst taking into account the needs of patients and dentists.